Dental Benefits

Insurance Provider:

United Health Care  Group# 681496

Waiting Period:

1st of Month Following 30 Days

Insurance Costs & Breakdown:

Employee Only Coverage

Total Annual Cost

$348.36

Employer Annual Cost

$348.36

Employee Annual Cost

$0.00

Employee Cost Per Paycheck

$0.00

Employee + Spouse Coverage

Total Annual Cost

$696.84

Employer Annual Cost

$348.36

Employee Annual Cost

$348.48

Employee Cost Per Paycheck

$13.40

Employee + Child(ren)Coverage

Total Annual Cost

$729.12

Employer Annual Cost

$348.36

Employee Annual Cost

$380.76

Employee Cost Per Paycheck

$14.64

Employee + Family

Total Annual Cost

$1,113.00

Employer Annual Cost

Employee Annual Cost

$348.36

$764.64

Employee Cost Per Paycheck

$29.41

Plan Type:

Calendar Year Max:

Deductible:

Preventative Services:

Included:

 

Basic Services:

Includes:

Major Services:

Includes:

 

Orthodontia:

Coinsurance/Max:

DPPO

$1,000

$50 (Ind) $150 (Fam) 

100% Ded. Waived 

Exams & Cleanings (2yr), X-Rays, Lab & Other Diagnostics Tests, Child Only Fluoride & Space Retainers 

80% After Ded. 

Filings, Simple & Surgical Extractions, Oral Surgery, Endo/Perio, Emergency Treatment 

50% After Ded. 

Inlays, Onlays, Crowns*, Dentures, Bridges*

Not Covered 

0% After Ded $1,500 Lifetime

*Your plan bases reimbursement on the least costly treatment alternative. A pre-treatment estimate is recommend for any service over $500.00. 

Platinum Control Technologies

2822 West 5th Street

Fort Worth, TX 76107

Service Office: Midland, TX

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